PILOT BUTTE REHABILITATION CENTER
1876 NE HIGHWAY 20, BEND, OR 97701
Meets federal staffing minimum — above average inspection record.
Quality Breakdown
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RN Staffing
Registered nurse time each resident receives daily. Federal minimum: 0.55 hrs.
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1.11 ✓ Meets federal minimum |
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Health Deficiencies
Violations found during federal inspections over the last 3 years.
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8 |
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CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
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Quality: ★★☆☆☆ (2/5)
Staffing: ★★★★☆ (4/5)
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NursingHomeGrade Score
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69/100 |
Data last updated: April 12, 2026
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
Most recent inspection (September 19, 2025)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 21, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 21, 2025
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected October 21, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 21, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 21, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 21, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 21, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 21, 2025
Inspection cycle 2 (April 17, 2024)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected May 14, 2024
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected May 14, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2024
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2024
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2024
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2024
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2024
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 10, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 14, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2024
Assist a resident in gaining access to vision and hearing services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2024
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2024
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2024
Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2024
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2024
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2024
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2024
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2024
Inspection cycle 3 (February 25, 2023)
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Environmental Deficiencies — Deficient, Provider has date of correction, corrected April 3, 2023
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected April 3, 2023
Perform COVID19 testing on residents and staff.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected April 3, 2023
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected April 3, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected April 3, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 3, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 3, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 3, 2023
Provide appropriate foot care.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 3, 2023
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected April 3, 2023
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected April 3, 2023
Provide care by qualified persons according to each resident's written plan of care.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected April 3, 2023
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 3, 2023
Quality Assurance & Integrity
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